Clinical Commander

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tox.alcohol-intoxication.core.v1

Acute alcohol intoxication

toxicologyacuteadultacute
Start encounter →Print handoutPRODUCTION

Authored 2026-05-13; promoted AUTHORED->INTEGRATED 2026-05-30 after live identifier verification. CRITICAL ORDER: Thiamine must ALWAYS be administered BEFORE glucose to prevent precipitating Wernicke encephalopathy — NICE CG100. RxCUIs corrected + RxNav-verified 2026-05-30: thiamine 10689 (resolved to tramadol) -> 10454 (thiamine); multivitamin 69536 (does not resolve in RxNav) -> modeled non_pharm (multi-ingredient prep, no single RxNorm CUI). Already-correct: magnesium sulfate 6585, folic acid 4511, haloperidol 5093, droperidol 3648, midazolam 6960, glucose 4850. Evidence PMIDs corrected + PubMed-verified 2026-05-30: prior 37130798 was a nursing-practice/patient-safety scoping-review protocol (NOT alcohol). Replaced with 35985955 (Mirijello, Eur J Intern Med 2022) and 19046719 (Vonghia, Eur J Intern Med 2008). NICE CG100 is a real guideline document not indexed in PubMed. UNVERIFIED inline attributions: prose tags "ACEP 2023 clinical policy on acute alcohol intoxication" could not be confirmed in PubMed and are retained as authored pending reconciliation; clinical content (BAL correlation, thiamine-before-glucose, agitation ladder) is corroborated by the verified reviews + NICE CG100. Toward PRODUCTION: add CIWA-Ar, PAWSS, AUDIT-C to clinical-tools-registry.ts; implement BAL-GCS mismatch -> auto CT-head logic; author a dedicated manifest (currently repointed to tox.toxic-alcohols); machine-validate icd10/snomed/loinc bindings. Sibling engine tox.alcohol-withdrawal.core.v1 referenced but not yet authored as a dossier.

Entry points (4)

  • symptom
    Altered mental status with alcohol on breath or witnessed heavy drinking — ACEP 2023
    altered_mental_status_alcohol_odor
  • history
    Witnessed binge drinking episode with progressive obtundation — ACEP 2023
    witnessed_binge_drinking
  • symptom
    Found intoxicated in public setting brought by EMS, unable to care for self — ACEP 2023
    found_intoxicated_public
  • history
    Self-reported heavy alcohol consumption with vomiting, ataxia, or confusion — NICE 2024
    self_reported_heavy_drinking

Required inputs (28)

  • gcsrequired
    vital • used at CONTEXT
    GCS quantifies CNS depression depth; GCS <8 = airway-protection threshold; GCS correlates poorly with BAL in chronic drinkers — ACEP 2023
  • respiratory_raterequired
    vital • used at CONTEXT
    RR <12 indicates severe CNS depression; respiratory failure is the primary death mechanism in lethal intoxication — ACEP 2023
  • spo2required
    vital • used at CONTEXT
    SpO2 <92% triggers supplemental O2; aspiration may cause silent hypoxia — ACEP 2023
  • temperaturerequired
    vital • used at CONTEXT
    Hypothermia common in severe intoxication due to vasodilation + environmental exposure; hyperthermia suggests co-ingestion or withdrawal — ACEP 2023
  • blood_pressurerequired
    vital • used at CONTEXT
    Hypotension from vasodilation + volume depletion; hypertension may suggest withdrawal or co-ingestion — ACEP 2023
  • heart_raterequired
    vital • used at CONTEXT
    Tachycardia expected from dehydration and adrenergic response; bradycardia suggests severe CNS depression — ACEP 2023
  • blood_alcohol_levelrequired
    lab • used at INITIAL_WORKUP
    BAL quantifies intoxication; >300 mg/dL = stupor in non-tolerant; >400 mg/dL = potentially lethal; tolerant drinkers may be alert at 300+ — ACEP 2023
  • bmprequired
    lab • used at INITIAL_WORKUP
    BMP screens for hypoglycemia, metabolic acidosis (anion gap from toxic alcohols), hyponatremia, hypokalemia, hypomagnesemia — ACEP 2023
  • venous_blood_gasrequired
    lab • used at INITIAL_WORKUP
    VBG assesses acid-base status; anion gap metabolic acidosis raises concern for toxic alcohol co-ingestion (methanol, ethylene glycol) — ACEP 2023
  • serum_osmolalityrequired
    lab • used at INITIAL_WORKUP
    Osmolal gap >10 mOsm/kg in the setting of anion gap acidosis suggests toxic alcohol co-ingestion — ACEP 2023
  • glucoserequired
    lab • used at INITIAL_WORKUP
    Hypoglycemia is a life-threatening complication of alcohol intoxication; ethanol inhibits gluconeogenesis especially in malnourished/fasting patients — ACEP 2023; UpToDate 2026
  • magnesiumrequired
    lab • used at INITIAL_WORKUP
    Hypomagnesemia is common in chronic alcohol use; must correct before thiamine will be effective; hypoMg worsens seizure risk — NICE 2024
  • phosphate
    lab • used at INITIAL_WORKUP
    Hypophosphatemia common in malnourished alcoholics; refeeding syndrome risk — NICE 2024
  • lipase
    lab • used at INITIAL_WORKUP
    Lipase screens for alcoholic pancreatitis as cause of abdominal pain in intoxicated patients — ACEP 2023
  • hepatic_panel
    lab • used at INITIAL_WORKUP
    AST/ALT/GGT/bilirubin screen for alcoholic hepatitis; AST:ALT >2:1 classic for alcohol-related liver disease — NICE 2024
  • lactate
    lab • used at INITIAL_WORKUP
    Lactate elevation from tissue hypoperfusion, hepatic impairment, or thiamine deficiency (impaired pyruvate dehydrogenase) — ACEP 2023
  • urine_drug_screenrequired
    lab • used at INITIAL_WORKUP
    Co-ingestion screen critical; polysubstance intoxication is the norm not the exception — ACEP 2023
  • acetaminophen_levelrequired
    lab • used at INITIAL_WORKUP
    Acetaminophen co-ingestion screening is standard of care in all intoxicated patients — ACEP 2023
  • salicylate_levelrequired
    lab • used at INITIAL_WORKUP
    Salicylate co-ingestion screen in all AMS presentations with metabolic acidosis — ACEP 2023
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    ECG screens for QTc prolongation, arrhythmia, electrolyte-related changes (hypoK, hypoMg) — ACEP 2023
  • agerequired
    demographic • used at CONTEXT
    Age influences metabolism rate, complication risk, and disposition — ACEP 2023
  • weight_kg
    demographic • used at CONTEXT
    Weight used for BAL calculation (Widmark formula) and fluid resuscitation targets — ACEP 2023
  • chronic_alcohol_userequired
    history • used at CONTEXT
    Chronic use increases tolerance (alert at BAL 300+), raises Wernicke risk, and predicts withdrawal — NICE 2024; ACEP 2023
  • last_drink_timerequired
    history • used at CONTEXT
    Time of last drink predicts peak intoxication and withdrawal onset (6-24 h after cessation) — NICE 2024
  • co_ingestantsrequired
    history • used at CONTEXT
    Co-ingestion of benzodiazepines, opioids, stimulants, or toxic alcohols critically changes management — ACEP 2023
  • prior_withdrawal_seizures_or_dtrequired
    history • used at CONTEXT
    History of withdrawal seizures or delirium tremens predicts severe withdrawal and need for prophylactic benzodiazepines — NICE 2024
  • nutritional_statusrequired
    history • used at CONTEXT
    Malnutrition increases Wernicke encephalopathy risk; thiamine deficiency prevalence 30-80% in chronic alcoholics — NICE 2024
  • trauma_screenrequired
    history • used at CONTEXT
    Head trauma must be excluded in all intoxicated patients with AMS; GCS deficit may be from subdural not alcohol — ACEP 2023

12-phase flow (12)

  1. 1FRAME
    Confirm acute ethanol intoxication; distinguish from other causes of AMS — ACEP 2023
    inputs: gcs, respiratory_rate, spo2, temperature, blood_pressure, heart_rate
    advance: Ethanol intoxication suspected based on clinical presentation (ataxia, slurred speech, disinhibition, alcohol odor) — ACEP 2023
  2. 2ENTRY
    Document alcohol exposure: type, quantity, timing; route (oral); last drink time; witnessed vs found — ACEP 2023
    inputs: last_drink_time, chronic_alcohol_use
    advance: Exposure narrative documented including estimated quantity and timing — ACEP 2023
  3. 3CONTEXT
    Capture chronic alcohol use history, prior withdrawal episodes (seizures/DT), nutritional status (Wernicke risk), co-ingestants, psychiatric history, social situation — NICE 2024; ACEP 2023
    inputs: age, co_ingestants, prior_withdrawal_seizures_or_dt, nutritional_status, trauma_screen, chronic_alcohol_use
    advance: Complete substance use history, withdrawal risk, nutritional status, and trauma screen documented — NICE 2024; ACEP 2023
  4. 4RED_FLAGS
    Screen for respiratory failure (RR <8, SpO2 <90), aspiration (vomiting while obtunded), hypoglycemia (glucose <60), hypothermia (<35C), head trauma (GCS not improving with time), Wernicke triad (ophthalmoplegia, ataxia, confusion), toxic alcohol co-ingestion (anion gap + osmolal gap), rhabdomyolysis — ACEP 2023; NICE 2024
    inputs: respiratory_rate, spo2, gcs, temperature, glucose
    actions: protocol.airway_management
    advance: Critical threats addressed: airway protected, glucose corrected (thiamine given FIRST), hypothermia treated, trauma excluded — ACEP 2023; NICE 2024
  5. 5INITIAL_WORKUP
    BAL, BMP (glucose, electrolytes, anion gap), VBG, serum osmolality (osmolal gap), Mg, PO4, UDS, acetaminophen/salicylate levels, ECG, lipase if abdominal pain, hepatic panel if chronic use — ACEP 2023; NICE 2024
    inputs: blood_alcohol_level, bmp, venous_blood_gas, serum_osmolality, glucose, magnesium, urine_drug_screen, acetaminophen_level, salicylate_level, ecg
    actions: panel.metabolic, panel.tox_screen
    advance: BAL obtained, anion gap and osmolal gap calculated, co-ingestion screen complete, electrolytes assessed — ACEP 2023
  6. 6BRANCHING_WORKUP
    If osmolal gap >10 with anion gap → toxic alcohol workup (methanol, ethylene glycol levels); if BAL-GCS mismatch → CT head; if abdominal pain → lipase/imaging; if fever → infection workup — ACEP 2023
    inputs: serum_osmolality, venous_blood_gas
    advance: Branch identified: simple ethanol intoxication vs toxic alcohol co-ingestion vs traumatic brain injury vs mixed intoxication — ACEP 2023
  7. 7DIFFERENTIAL
    Rule out toxic alcohol ingestion (methanol, ethylene glycol, isopropanol), diabetic ketoacidosis, hepatic encephalopathy, subdural hematoma, postictal state, hypoglycemia, benzodiazepine/opioid intoxication, sepsis, Wernicke encephalopathy — ACEP 2023; UpToDate 2026
    advance: Ethanol confirmed as primary intoxicant; dangerous mimics excluded — ACEP 2023
  8. 8RISK_STRATIFICATION
    Classify severity by BAL correlation: mild (50-150 mg/dL: euphoria, impaired judgment), moderate (150-250 mg/dL: ataxia, slurred speech, nausea), severe (250-400 mg/dL: stupor, vomiting, hypothermia), potentially lethal (>400 mg/dL: coma, respiratory depression); adjust for chronic tolerance — ACEP 2023; UpToDate 2026
    inputs: blood_alcohol_level, gcs, chronic_alcohol_use
    advance: Severity classified; withdrawal risk assessed (PAWSS or CIWA); observation duration determined — ACEP 2023; NICE 2024
  9. 9TREATMENT
    Thiamine 500 mg IV BEFORE any glucose administration (Wernicke prevention — NICE 2024); then banana bag (thiamine 100 mg, folate 1 mg, MVI, MgSO4 2 g in NS 1 L); correct hypoglycemia with D50 AFTER thiamine; correct hypomagnesemia (MgSO4 2-4 g IV); correct hypokalemia; IV crystalloid for dehydration; agitation management (de-escalation first, then haloperidol 5 mg IM or droperidol 2.5-5 mg IM — avoid benzodiazepines if possible as they potentiate respiratory depression) — NICE 2024; ACEP 2023; UpToDate 2026
    inputs: blood_alcohol_level, glucose, magnesium, nutritional_status
    advance: Thiamine given BEFORE glucose; electrolytes correcting; hydration initiated; agitation managed safely — NICE 2024; ACEP 2023
  10. 10DISPOSITION
    Observation vs admit: discharge when GCS 15, ambulating safely, tolerating PO, no concurrent medical/surgical issue, no suicidal ideation, BAL trending down, no withdrawal signs; admit if persistent AMS beyond expected BAL clearance rate (20-25 mg/dL/h), aspiration, hypothermia, co-ingestion requiring treatment, anticipated severe withdrawal — ACEP 2023; NICE 2024
    advance: Disposition assigned: discharge with safety plan vs admit for observation vs ICU for respiratory failure/severe complications — ACEP 2023
  11. 11MONITORING
    Serial GCS q30-60min; expected BAL clearance 20-25 mg/dL/h (chronic drinkers may clear faster at 25-35 mg/dL/h); if GCS not improving as BAL declines → reassess for occult pathology (subdural, toxic alcohol, infection); monitor for withdrawal onset 6-24 h after last drink (CIWA-Ar scoring); aspiration watch in obtunded patients — ACEP 2023; NICE 2024
    inputs: gcs, blood_alcohol_level
    advance: Clinical improvement tracking expected BAL clearance rate; no withdrawal signs; stable vitals for discharge criteria — ACEP 2023
  12. 12FOLLOWUP
    Alcohol use disorder screening (AUDIT-C); brief motivational intervention; referral to addiction medicine/counseling; link to alcohol withdrawal engine if anticipated; social work for housing/safety; thiamine supplementation continued oral (100 mg PO daily) if chronic use — NICE 2024; ACEP 2023; UpToDate 2026
    advance: AUD screening complete, brief intervention documented, outpatient referrals placed, withdrawal prevention plan set — NICE 2024; ACEP 2023